Summary

Summary: Certified Project Management Professional PMP , B.S. Computer Science. Over twenty years of Business and IT Project Management Life Cycle PMLC and Software Development Life Cycle SDLC and process improvement experience via the Project Management Institute PMI PMBOK and Software Engineering Institute SEI /Capability Maturity Model CMM . Experienced in healthcare systems with major insurance carriers including Boston Medical Center HealthNet Plan BMCHP , Horizon Blue Cross Blue Shield of New Jersey BCBSNJ , Carefirst Blue Cross Blue Shield of Maryland, Pennsylvania Employees Benefit Trust Fund Third Party Administrator .

Work Experience:

Confidential

• Responsible for managing, in conjunction with the technical lead, the development of the .Net framework used to integrate disparate systems which provide for world wide product selection and ordering.
• Utilized PMO project management portfolio of processes and procedures
• Accountable for project management plan, project schedule in Microsoft project, budgeting/forecasting, status reporting, risk management, issue management, action item management, SOW development, change control, decision logs, meeting facilitation, procurement of software/licenses, and procurement of project personnel. Participated in weekly web architect meetings, Facilitated cross department communication. Managed tiger team to ensure release completed on time.
• Communicated and worked with business sponsor, PMO, SMEs, IT technicians, off shore and on-site resources
• Utilized Agile SDLC methodology - conducted sprint planning, sprint reviews, sprint retrospective, participated in daily scrums
• Technical tools included .Infragistics, Ecrion, Clip One, Log4net, SignalR, C , Resharper

Confidential

• Responsible for the management of activities related to the transition of the State of New York behavioral health systems from Optum Health to ValueOptions Corporation.
• Contract terminated due to protest won by Optum Health to overturn the decision to utilize ValueOptions as the vendor.

Confidential

Responsible for the phase out of the IBC IT enrollment processing department as it was transferred to Highmark.

Confidential

• Responsible for implementation of federal and state mandates related to the business integration of health care initiatives.
• Utilized PMO project management portfolio of processes and procedures
• Accountable for status reporting, development of success metrics, red/yellow/green reporting, risk management, issue management, lessons learned, go live reviews, communications plans, change control, project closure reports, project initiation work groups, Q A logs and meeting scheduling, facilitation and documentation.
• Communicated and worked with business sponsors, business owners, SMEs, IT technicians, off site and on-site resources
• Core project teams consisted of affected project managers, FACETS, NetworX, iCES, OPTUM Pricer, configuration analysts, benefit definition team, payment policies team, benefit and clinical coders and testing/QA analysts
• Software included MS-Project and MS-Visio.
• The following are three projects that are currently being worked:
• Dual Eligibility
• The project allows BMCHP to provide services for individuals who are dually eligible for Medicare and Medicaid.
• Definition of plan benefits, FACETS configuration, iCES configuration, QA and Testing
• Management of 17 project personnel
• Participate in weekly steering committee meeting and project management meetings
• Affordable Care Act Primary Care Physician ACA - PCP Rate Increase
• Section 1202 of the ACA requires Medicaid agencies to provide payment for certain primary care services delivered by eligible physicians and for specific codes at no less than Medicare Rates for the years 2013 and 2014.
• Definition of plan benefits, FACETS configuration, QA and testing
• Management of twenty personnel
• International Classification of Diseases version 10 ICD-10
• ICD-10 is a mandatory compliance initiative that requires all health care payers and providers to convert from ICD-9 codes to ICD-10 codes and be compliant by the proposed implementation date of October 1, 2014.
• Scope definition, WBS, Network diagramming, activity definition, resource requirements, activity durations, project schedule
• FACETS configuration
• Steering committee

Confidential

• Responsible for implementation of federal and state mandates related to health care initiatives.
• Utilized EPMO project management portfolio of processes and procedures
• Accountable for financial planning, accruals, status reporting, development of success metrics, red/yellow/green reporting, risk management, issue management, funding gate reviews, stakeholder reviews, lessons learned, go live reviews, internal and external communications plans, change control, data elicitation, operations and support plans, process flows, project closure reports, kickoff meetings, project surveys, and Q A logs.
• Reviewer and approver of RTM, HLR, TRD, SIPOC, FEMA, solution options, training, SIT and UAT.
• Communicated and worked with business sponsors, business owners, SMEs, IT technicians, Network management, off shore and on shore testing.
• Core project teams consisted of manager project controls, project business analyst, project scheduler, project administrator/coordinator, SME, compliance manager, DPMO and EPMO.
• Software included Planview, MS-Project and MS-Visio.
• The following are five projects that were worked:
• CMS Medicare Advantage Collection of Encounter Data
• HIPAA 5010 compliance on the submission of encounter data to CMS's Encounter Data System EDS, EDFES, EDPS using EDI 837P Professional , I Institutional and Durable Medical Equipment DME transactions and responses from CMS utilizing EDI 277, 277 CA and 999 transactions.
• Managed a team of 21 project personnel within a project budget of 800K.
• The project allows Horizon to continue to receive reimbursements from CMS in the amount of 600M per year.
• Interviewed and selected a vendor to act as a third party submitter to CMS.
• Participated in work group calls with Americas Health Insurance Plans AHIP and CMS.
• Managed Care Plans Pay Claims on Assignment of Benefits AOB
• Mandate dictated an increased threshold for provider payments from 5K to a threshold of 10K. Modification of processing was also done to include assistant surgeons within the enterprise.
• The project required the modification of the QBlue and NASCO claim engines.
• Managed a core team of ten personnel with a project budget of 600K.
• The end result of the project was an estimated network savings of 3.3M.
• Maternity Installment Payments
• Mandate allowed providers with the Horizon network to select to receive equal installment payments for services rendered during the term or a pregnancy.
• Conduct impact assessments for twenty-five functional areas.
• Facilitated meeting for over 45 functional personnel associated with the project and the various components affected including QBlue, NASCO, claim stop governance, provider relations, provider network operations PNO , provider correspondence.
• Project budget of 226K.
• Prior authorization remediation
• Based upon internal audit findings member payments were being denied in full if no prior authorization. The regulation stated that the penalty could not exceed more than 50 of the payment amount.
• Accountable for impact assessment within the enterprise, development of scope statement, work breakdown structure, business requirements document, interviewing of 15 functional areas CPW, CareCore, IVR, CPL, EOB, Benefit Coding, Legal, Contracts, Sales, Provider relations, Compliance, QBlue, NASCO, Correspondence, Learning and Development
• Project plan and budget of over 300K to accommodate the team and processing required.
• Negative ROI 1.36M over five years.
• EOB Messaging
• New Jersey Department of Banking and Insurance DOBI and CMS cited Horizon for EOB messages that did not provide specific reason for the service/claim denial.
• The project required the analysis and refinement of over 5K EOB messages by utilizing Pareto analysis to determine messages with the most impact.
• There are 5 distinct work streams to facilitate the project.
• The project budget is nearly 2M.
• Currently developing a solution options document problem statement, solution requirements, success criteria, solutions, pros, cons, risks, assumptions, costs, recommendation to provide benefit variable messaging, estimated costs is 16M to complete the effort on one work stream.
• JAD sessions were conducted to develop three business requirements documents.
• These documents are being approved by the enterprise so NASCO can be engaged to complete the work stream development efforts.